Aims. Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome. Cite this article: Bone Jt Open 2024;5(9):729–735

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction. Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning. We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance. Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension. Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital

Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds. Operating room (OR) in and out times and surgical times were collected via EMR electronic and manual data extraction with verification. Multivariate statistical analyses were utilized with p<0.05 significant. Results. 1261 DA approach (43%) and 1647 posterior approach (57%) THAs were analyzed. Mean total OR time, including anesthesia and positioning, was greatest for hospital-based DA THAs (146 mins), followed by hospital posterior approach THAs (126.4 mins), ASC-based DA THAs (118.1 mins) and ASC posterior THAs (90.1 mins) (p<0.001). In multivariate analysis, compared to the optimal ASC posterior approach group, the total OR time predictive model added 31 minutes per ASC DA THA, 33 minutes per hospital posterior THA, and 56 minutes for hospital DA THA (p<0.001). Similar predictive effect was observed for surgical time, which added 18 minutes per ASC-based DA THA, 22 minutes for hospital posterior THA and 29 minutes for hospital DA THA (p<0.001). Conclusion. In the COVID era, efficiency should be enhanced to maximize patient access for elective procedures and facilitate the healthcare system financial recovery. Despite equivocal clinical results, DA approach THA consumes substantially more OR time when compared to the posterior approach in both the hospital and ASC setting

Aims. The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. Patients and Methods. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. Results. Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. Conclusion. The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116–122

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). DAA THA is increasing, particularly among surgeons who have learned the technique during overseas fellowships. Whether DAA offers long-term clinical benefit is unclear. We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multi-centre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10-year Oxford Hip Score (OHS) and 10-year revision rates. 125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10-year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value <0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point post-op the OHS for DAA THA was 42.63, 42.10 for posterior THA and the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point. Whilst there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistically significant difference between the outcome measures or revision rates for the two approaches

Introduction: Despite the advances in total hip arthroplasty (THA), a dislocation after THA remains a disturbing complication. Dislocation after revision hip arthroplasty has been an underemphasized cause of failure in revision hip arthroplasty despite its higher dislocation rate than after primary THA. The effectiveness of posterior soft tissue repair in the posterior approach has been determined in primary THA. However, to the best of our knowledge, there are no reports dealing specifically with the effectiveness of posterior soft tissue repair in the posterior approach in revision hip arthroplasty. We investigated the influence of the posterior approach with soft tissue repair in revision hip arthroplasty by evaluating the rate of early posterior dislocation. Material and Method: Ninety-one patients (96 hips) who had undergone revision hip arthroplasty through the posterior approach were observed for 1 year or until dislocation occurred. Fifty-six revision hip arthroplasties were performed using the posterior approach with soft tissue repair technique. The results of these procedures were compared with those of 40 revision hip arthroplasties that had been performed using the posterior approach without soft tissue repair. Results: The dislocation rate of 10.0% in 40 hips using the posterior approach without soft tissue repair was reduced to 1.9% in 56 hips using the posterior approach with soft tissue repair. Discussion: Considering the results, it is clear that the posterior soft tissue repair in revision hip arthroplasty is clinically important for achieving a lower dislocation rate after revision hip arthroplasty. We suggest that to prevent dislocation after revision hip arthroplasty when a posterior approach is used, the posterior soft tissue, including the capsule and short external rotators, should be preserved and repaired as much as possible

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

Range of Motion (ROM) assessments are routinely used during joint replacement to evaluate joint stability before, during and after surgery to ensure the effective restoration of patient biomechanics. This study aimed to quantify axial torque in the femur during ROM assessment in total hip arthroplasty to define performance criteria against which hip instruments can be verified. Longer term, this information may provide the ability to quantitatively assess joint stability, extending to quantitation of bone preparation and quality. Joint loads measured with strain-gaged instruments in five cadaveric femurs prepared using posterior approach were analysed. Variables such as surgeon-evaluator, trial offset and specimen leg and weight were used to define 13 individual setups and paired with surgeon appraisal of joint tension for each setup. Peak torque loads were then identified for specific motions within the ROM assessment. The largest torque measured in most setups was observed during maximum extension and external rotation of the joint, with a peak torque of 13Nm recorded in a specimen weighing 98kg. The largest torque range (19.4Nm) was also recorded in this specimen. Other motions within the trial reduction showed clear peaks in applied torque but with lower magnitude. Relationships between peak torque, torque range and specimen weight produced an R2 value greater than 0.65. The data indicated that key influencers of torsional loads during ROM were patient weight, joint tension and limb motion. This correlation with patient weight should be further investigated and highlights the need for population representation during cadaveric evaluation. Although this study considered a small sample size, consistent patterns were seen across several users and specimens. Follow-up studies should aim to increase the number of surgeon-evaluators and further vary specimen size and weight. Consideration should also be given to alternative surgical approaches such as the Direct Anterior Approach

Introduction. The hip hemiarthroplasty in posterior approach is a common surgical procedure at the femoral neck fractures in the elderly patients. However, the postoperative hip precautions to avoid the risk of dislocations are impeditive for early recovery after surgery. We used MIS posterior approach lately known as conjoined tendon preserving posterior (CPP) approach, considering its enhancement of joint stability, and examined the intraoperative and postoperative complications, retrospectively. Methods. We performed hip hemiarthroplasty using CPP approach in 30 patients, and hip hemiarthroplasty using conventional posterior approach in 30 patients, and both group using lateral position with the conventional posterior skin incision. The conjoined tendon (periformis, obturator internus, and superior/inferior gemellus tendon) was preserved and the obturator externus tendon was incised in CPP approach without any hip precautions postoperatively. The conjoined tendon was incised in conventional approach using hip abduction pillow postoperatively. Results. There was no difference between CPP approach group and conventional approach group in the mean age of patients (81.8 years, and 80.3 years, respectively), and in the mean operative time (68.8 minutes, and 64.9 minutes, respectively). In 4 cases of CPP approach, the avulsion fracture at femoral attachment of the conjoined tendon occured during hip reduction manoeuvres. No dislocations occured in both groups in the follow-up period (2 years). Discussion. Lately, the number of hip surgery in muscle sparing approach is increasing. However, in general, MIS approach induces the intraoperative complications, and requires the skillful procedure. The hip reduction manoeuvres would be more difficult in the CPP approach, than in conventional posterior approach, because the preserved conjoined tendon would inhibit hip reduction, considering those avulsion fractures of the femoral attachment. Nevertheless, CPP approach did not require no extended time compared to conventional approach, and no postoperative hip precautions. Due to these results, CPP approach could be a good MIS procedure including early recovery after surgery based on the enhancement of joint stability, excluding the difficulties in hip reduction manoeuvres. We could not show the difference in dislocation rate between two groups, because of small numbers. We are planning to increase the number of patients in the future study

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches. Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS. Aim: To find out the affect of surgical approach on oxford hip score. Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem and were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS. Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively. Conclusion: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posterior approach to the hip. We present the first systematic review and meta-analysis of these two approaches. Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hip arthroplasties were included. The mini-incision posterior approach was associated with an early improvement in Harris hip score of 1.8 points (P < 0.001), reduced operating time (5 minutes, P < 0.001), length of hospital stay (14 hours, P < 0.001), intraoperative and total blood loss (63 ml, P < 0.001 and 119 ml, P < 0.001 respectively). There were no statistically significant differences on the incidence of dislocation, nerve injury, infection or venous thromboembolic events. The minimally invasive posterior approach appears to provide a safe and acceptable alternative to the standard incision posterior approach

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective. We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed. Cite this article: Bone Joint J 2013;95-B:1527–32

We investigated the relationship of the inferior gluteal nerve to gluteus maximus by dissecting the muscle in 12 fresh-frozen and formalin-treated cadavers. The anatomy was recorded using still digital photography. The course of the inferior gluteal nerve was carefully traced and was noted to enter the deep surface of gluteus maximus approximately 5 cm from the tip of the greater trochanter of the femur. The susceptibility of the nerve to injury during a posterior approach to the hip may be explained by its close relationship to the deep surface of gluteus maximus. It is easily damaged before it has been seen if the muscle is split and parted more than 5 cm from the tip of the greater trochanter of the femur. We suggest that a modified posterior approach be used to expose the hip to avoid damage to this nerve

Background:. Modified posterior approach and its effect on stability and functional outcome in total hip arthroplasty. Material & Methods:. A retrospective comparative evaluation was done to assess the functional outcome and rate of dislocation in 233 hips (Group A) operated before 2007 by convention posterior approach and 567 hips (Group B) were operated by modified posterior approach.(2007–2011) In this modified posterior approach technique, 2–3 stay sutures (non-absorbale Nylon) are applied in the piriformis tendon, short external rotator and proximal part of Quadratous muscle. Then a conjoint- myocapsular sleeve is raised by starting cutting (with cautery) linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus to expose and dislocate the head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured with same nonabsorbable Nylon at the lower part of tip of greater trochanter by passing through the bone with needle or by drilling the bone; lower part of the sleeve is tied with lateral trochanteric bone. Additional stability to repair was given by closing the tendinous part of the gluteus maximus by horizontal cross mattress sutures up its attachment to the proximal femoral shaft. Results:. All patients underwent cementless total hip arthroplasty; average Harris hip score at minimum 3.1 yr follow was 88.7 in Group B & 85.2 in Group B. Group B had only one dislocation while Group A had 12 dislocations (5%). Conclusion:. This technique provide enhanced stability and improve functional outcome

Introduction:. The routine use of posterior hip dislocation precautions is typically utilized postoperatively following total hip arthroplasty via a posterior surgical approach. This has included use of an abduction pillow and limiting adduction, internal rotation and flexion more than 90 degrees for a minimum of 6 weeks postoperatively. This may slow the course of rehabilitation, increase the length of hospital stay and the total cost of the procedure, and add additional anxiety to the patient. We conducted this study to see if posterior hip precautions are necessary after total hip arthroplasty via a posterior approach when the hip meets certain intraoperative criteria for stability. Methods and Materials:. All patients in our institute undergo routine hip stability testing during primary total hip arthroplasty via a posterior approach. Before October 2010, all of our primary total hip arthroplasty patients were placed on routine hip precautions. We stopped hip precautions in October 2010 for all the patients who were noted to meet hip stability criteria intraoperatively. We prospectively compared the consecutive patients who underwent this procedure without hip precautions with a retrospective control group of patients who had hip precautions. Results:. we had 650 patients in each group. In the case group, there was 1 postoperative dislocation (0.2%) within the first 3 months after surgery. In the control group (with hip precautions), 2 patients (0.3%) sustained hip dislocation within 3 months after surgery (p = 0.5). The mean hospital stay was 2.5 (0–11) days for the case group and 2.7 (1–9) days for the control group (p = 0.03). Patients in the case group were discharged to home more often compared to the control group (83.7% versus 83.4%), but the difference was not significant (p = 0.48). There was no difference in the Harris Hip score improvement between the two groups. Higher percentage of the patients in the case group received larger femoral head implant (35% versus 14%, p < 0.001) and elevated rim polyethylene liner (70% versus 57%, p < 0.001). Conclusion:. Intraoperative hip stability testing is necessary for all patients who undergo primary total hip arthroplasty via a posterior approach. If the hip is not stable intraoperatively, the surgeon should ensure that all sources of potential instability have been evaluated and managed. This may include implant sizing, implant position, and all sources of internal and external impingement. Use of a larger diameter head and elevated rim polyethylene may help with the stability of the hip. If the hip meets our stability criteria intraoperatively, we feel that formal hip precautions may not be necessary postoperatively

Aims. Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied. Methods. In an observational cohort study on 8,031 FNF patients with THA between January 2005 and December 2014, Swedish Arthroplasty Register data were linked with the National Patient Register, recording the total dislocation rates at one year and revision rates at three years after surgery. The cumulative incidence of events was estimated using the Kaplan-Meier method. Cox multivariable regression models were fitted to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of dislocation, revision, or mortality, stratified by surgical approach. Results. The cumulative dislocation rate at one year was 8.3% (95% CI 7.3 to 9.3) for patients operated on using the posterior approach and 2.7% (95% CI 2.2 to 3.2) when using the direct lateral approach. In the posterior approach group, use of DMC was associated with reduced adjusted risk of dislocation compared to 32 mm heads (HR 0.21 (95% CI 0.07 to 0.68); p = 0.009). This risk was increased with head sizes < 32 mm (HR 1.47 (95% CI 1.10 to 1.98); p = 0.010). Neither DMC nor different head sizes influenced the risk of revision following the posterior approach. Neither articulation was associated with a statistically significantly reduced adjusted risk of dislocation in patients where the direct lateral approach was performed, although this risk was estimated to be HR 0.14 (95% CI 0.02 to 1.02; p = 0.053) after the use of DMC. DMC inserted through a direct lateral approach was associated with a reduced risk of revision for any reason versus THA with 32 mm heads (HR 0.36 (95% CI 0.13 to 0.99); p = 0.047). Conclusion. When using a posterior approach for THA in FNF patients, DMC reduces the risk of dislocation, while a non-significant risk reduction is seen for DMC after use of the direct lateral approach. The direct lateral approach is protective against dislocation and is also associated with a lower rate of revision at three years, compared to the posterior approach. Cite this article: Bone Joint J 2022;104-B(7):844–851

Aims. It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. Methods. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services. Results. The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group. Conclusion. The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078–1087

Despite a lack of long-term follow-up, there is an increasing trend towards using femoral heads of large diameter in total hip replacement (THR), partly because of the perceived advantage of lower rates of dislocation. However, increasing the size of the femoral head is not the only way to reduce the rate of dislocation; optimal alignment of the components and repair of the posterior capsule could achieve a similar effect. . In this prospective study of 512 cemented unilateral THRs (Male:Female 230:282) performed between 2004 and 2011, we aimed to determine the rate of dislocation in patients who received a 22 mm head on a 9/10 Morse taper through a posterior approach with capsular repair and using the transverse acetabular ligament (TAL) as a guide for the alignment of the acetabular component. The mean age of the patients at operation was 67 years (35 to 89). The mean follow-up was 2.8 years (0.5 to 6.6). Pre- and post-operative assessment included Oxford hip, Short Form-12 and modified University of California Los Angeles and Merle D’Aubigne scores. The angles of inclination and anteversion of the acetabular components were measured using radiological software. There were four dislocations (0.78%), all of which were anterior. In conclusion, THR with a 22 mm diameter head performed through a posterior approach with capsular repair and using the TAL as a guide for the alignment of the acetabular component was associated with a low rate of dislocation. Cite this article: Bone Joint J 2014;96-B:1202–6

Introduction. Computer navigation systems are quite sophisticated intra-operative support systems for the precise placement of acetabular or femoral components in THA. However, few studies have addressed the clinical benefits derived from using a navigation system to achieve precise placement of the implants. The purpose of this study is to investigate the early dislocation rate of navigation-assisted primary THA through a posterior approach in order to clarify the short-term benefit of using a computer navigation system. Methods. We retrospectively reviewed the early dislocation rate (within 12 months after surgery) of 475 consecutive primary cementless or hybrid THAs with femoral head sizes ≦32mm performed via posterior approach. There were 85 men and 390 women, with a mean age of 60 years (17 to 88) at operation. Preoperative diagnoses included osteoarthritis in 384 hips, osteonecrosis in 45 hips, and others in 46 hips (ex. RA, trauma, infection, congenital disease). All THAs were planned using a 3D templating system based on the combined anteversion theory, performed by single surgeon through a posterior approach with repair of the posterior capsule, assisted by a CT-based surface matching type computer navigation system for cup implantation. All patients were directly followed up at least 1 year after surgery. We classified all 475 joints into four groups: normal or mildly deformed hips (Group A; 308 joints, ex. primary OA, Crowe group 1, osteonecrosis), moderately deformed hips (Group B; 97 joints, ex. Crowe group 2, protrusio acetabuli, Perthes like deformity), severely deformed hips (Group C; 53 joints, ex. Crowe group 3 or 4, ankylosis, fused hip), and neuromuscular and cognitive disorders (Group D; 17 joints), and examined the dislocation rate for each group. Results. We had eleven early dislocations, for an overall dislocation rate of 2.3% (11/475). All dislocations occurred posteriorly within 6 weeks after surgery. Three joints were Crowe group 4 dislocated hips, three were Charcot joints, two were Girdlestone hips after pyogenic arthritis, two was a Crowe group 1 hip, and one was osteonecrosis. All 11 cups were implanted within 5 degree of error from the preoperative planning, and all were placed within the Lewinnek safe zone. The dislocation rates according to group were 0.6% for group A (2/308), 0% for B (0/97), 9.4% for C (5/53), and 23.5% for D (4/17). Discussion. The use of computer navigation system in patients undergoing THA improves the precision of acetabular cup placement by decreasing the number of outliers, which may result in reducing the risk of dislocation. In this series, most dislocations occurred in the highly risky or rare condition cases in groups C or D. In such cases, precise and appropriate cup implantation assisted by the navigation system could not completely prevent dislocation because of the patients' specific special backgrounds. On the other hand, early dislocation was prevented for the normal/mild to moderately deformed joints such as those in groups A or B. Computer navigation system was effective for prevent early dislocation in the normal or mild to moderately deformed joints

The angle of inclination of the acetabular component in total hip replacement is a recognised contributing factor in dislocation and early wear. During non-navigated surgery, insertion of the acetabular component has traditionally been performed at an angle of 45° relative to the sagittal plane as judged by the surgeon’s eye, the operative inclination. Typically, the method used to assess inclination is the measurement made on the postoperative anteroposterior radiograph, the radiological inclination. The aim of this study was to measure the intra-operative angle of inclination of the acetabular component on 60 consecutive patients in the lateral decubitus position when using a posterior approach during total hip replacement. This was achieved by taking intra-operative photographs of the acetabular inserter, representing the acetabular axis, and a horizontal reference. The results were compared with the post-operative radiological inclination. The mean post-operative radiological inclination was 13° greater than the photographed operative inclination, which was unexpectedly high. It appears that in the lateral decubitus position with a posterior approach, the uppermost hemipelvis adducts, thus reducing the apparent operative inclination. Surgeons using the posterior approach in lateral decubitus need to aim for a lower operative inclination than when operating with the patient supine in order to achieve an acceptable radiological inclination

The optimum approach for Total Hip Arthroplasty is hotly debated. Many surgeons, especially the newly trained, have been wary of the . posterior approach. because of higher reported rates of dislocation. We analysed 137 consecutive patients who underwent Primary Total Hip Replacement for Osteoarthritis during the first three years of practice of a newly appointed consultant with an interest in hip and knee arthroplasty. All surgeries were either performed by or under the direct supervision of the senior author. The posterior capsule and short external rotators were reattached to the Greater Trochanter as a routine. Data was gathered prospectively by proforma for all the patients, one at the time of operation and one each at 3 months and 12 months from the surgery. 4 patients died due to causes unrelated to their arthroplasty (2.9%) and 6 patients (4.3%) were lost to follow up. The patients were grouped into A, B and C depending on involvement of one hip, both hips and multiple joint diseases respectively and the patients were analysed for pain scores (1–6), function scores (1–6) and satisfaction levels (1–5) after the surgery. All the complications during and after surgery were noted, and special emphasis was laid on the incidence of dislocation, and factors contributing to it. The results were compared with the incidence reported in the literature for posterior and other approaches. The results were gratifying and were comparable with major series of Total Hip Replacement via the posterior approach. Only one patient (0.7%) had a dislocation. This occurred during the index admission when the patient sat down on a ward toilet without a raised toilet seat. The hip was reduced under General Anaesthesia and he had no problem thereafter. 122 patients (96%) had no pain or minimal pain not limiting the activity after the surgery but 5 patients (4%), 3 from Group C had activity related pain or pain at rest. 93 patients (73%) were walking without a stick after surgery and 34 patients (27%) were using a stick for extra safety. 5 patients (4%) had superficial infection which settled with antibiotics and one patient (0.7%) had deep infection which required a Revision hip surgery. 6 patients developed Deep Vein Thrombosis (4.7%) and one patient (0.7%) had Pulmonary Embolism but all the patients returned to good function after treatment. One patient (0.7%) developed transient Sciatic nerve palsy but recovered completely. We conclude that the posterior approach, already known to cause less blood loss and to allow optimum component positioning and alignment, is compatible with a low overall rate of early complications. Specifically, the dislocation rate is low and comparable with large series performed by approaches traditionally considered to carry a lower rate of dislocation

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores, VAS Pain, and Modified Harris Hip Scores (mHHS). Post-operatively, the DAA group had decreased length of stay [1.4 vs 2.2 days, p=0.0002] and increased distance walked on postoperative day 1 and 2 [95 vs 52 ft, p=0.011 and 251 vs. 163 ft, p=0.0004, respectively]. The DAA group had lower VAS pain scores [p<0.05] and required less day 1 and total narcotics [59 vs 80 morphine equivalents, p=0.029 and 138 vs 190, p=0.01, respectively]. The DAA cohort had improved PROMIS Physical Function scores and mHHS up to 5 weeks post- operatively. Anterior approach patients discontinued their assistive device 8 days earlier [p=0.01], left home 3 days earlier [p=0.001], and drove a car 5 days earlier [p=0.016] compared to posterior patients. Conclusion. Patients undergoing DAA THA had significantly shorter length of stay, improved mobilization, decreased narcotic requirements and improved inpatient VAS pain scores compared to mini-posterior THA. Furthermore, DAA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients. The significant improvement in physical function seen with DAA THA persisted up to 5 weeks post-operatively

Modified posterior approach preserving short external rotators would be able to contribute greatly to prevent dislocation after total hip arthroplasty. We modified the posterior approach to the hip by preserving the external rotator muscles in order to enhance joint stability after total hip arthroplasty in patients with osteonecrosis of the femoral head. The aim of the this study was to determine the influence of external rotator preserving posterior approach in primary total hip replacement on early dislocation and clinical outcome. Three hundred sixty-four primary total hip replacements were divided into two groups based on how the external rotators were treated at surgery. External rotator preservation (Group 1, 165 hips) group was compared with reattachment (Group 2, 199 hips) group by evaluating the clinical and radiographic outcome at one year postoperative. Anteversion was significantly less in Group 1 as compared to Group 2 (P < 0.001). There was no significant difference in inclination between the groups (P > 0.05 in all comparisons). No dislocations were found in 165 hips with external rotator preservation whereas dislocations was noted in 11 (3.9%) in Groups 2, respectively. Group 1 had the higher mean Harris hip score (97.2±2.9 points) as compared with Group 2(94.9±3.4). The results of this study showed that external rotators could play an important role in preserving joint stability after total hip arthroplasty in patients with osteonecrosis of the femoral head. It can be implied that this modified posterior approach would be able to contribute greatly to prevention of dislocation, and improve clinical outcome after total hip arthroplasty

Introduction and Aims: Minimal Invasive Surgery (MIS) in THR surgery offers potential advantages over standard techniques. A user-friendly surgical technique has been developed via the posterior approach to the hip using a single six to eight centimetre incision, and requiring no special instrumentation other than three long Homan retractors of standard design. The technique has been used to date in 80 sequential non-obese patients undergoing both uncemented and cemented THRs. Method: Five cemented and 75 uncemented THR procedures were performed in the lateral position via a segment of the standard posterior approach incision, centred just behind the greater trochanter. The pre- and post-operative SF12, WOMAC, Harris hip score and Pain score were assessed prospectively; blood loss, theatre time and intra-operative and post-operative complications were charted, and compared with 40 matched standard incision patients. Cup and stem component positioning was assessed radiologically. The Body Mass Index (BMI) and the incision length were charted in each patient. The post-operative time to full weightbearing and stair climbing was charted. Results: There was no statistical difference in SF12, WOMAC, Harris hip score and Pain score in the two groups of patients. Blood loss was slightly reduced, but theatre time and intra-operative and post-operative complications were not increased. Cup and stem positioning on x-ray was not compromised. Immediate full weightbearing was allowed, including stair climbing post-operatively in all patients. Conclusion: MIS THR via the posterior approach is a safe and reproducible procedure, for both cemented and uncemented prostheses. It requires no special instrumentation or long learning phase for the experienced hip surgeon. Blood loss, theatre time and morbidity have not been increased, allowing a rapid discharge program as a routine

Aim. To evaluate efficacy of a one stage posterior approach in decompression and eradication of infection in TB spine. Background. The classic operation for TB spine is anterior spine debridement. This involves a trans-thoracic, or retroperitoneal approach, thus increasing morbidity in an already compromised patient. The anterior procedure in the form of the Hong Kong operation is aimed at decompressing the spine, and debridement of necrotic tissue. If kyphosis is a major problem, its correction requires a posterior procedure, often not at the same sitting. Material and Method. A retrospective review of patients treated surgically for TB Spine during the time period 2009–2012. We examined the records of those patients that were treated by a posterior only approach. We took note of the demographics of the patients. We measured the efficacy of the decompression by measuring the pre op and post op neurologic status as measured by the Frankel grading. The efficacy of debridemide was assessed by measuring the preoperative and follow up ESR. Results. We identified 11 patients for review, 8 male and 3 females. 8 were HIV positive. The disease affected the thoracic spine. The average follow up was 12 months. There was good correction of the deformity and this was maintained throughout the follow up period. The ESR decreased in all the patients. Neurologic improvement was noted in 5 patients and no patients deteriorated. Statistical methods to quantify these changes were not significant because of the small numbers. Conclusion. In our environment a number of patients are immunocompromised by the HIV virus. A trans thoracic approach increases the morbidity in these patients. Effective decompression and debridement can be achieved by the posterior only approach. NO DISCLOSURES

Introduction. The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol. Patients/Materials & Methods. Prospectively collected data for both cohorts were matched for age, gender, ASA grade, BMI, operation side, Pre-operative Oxford Hip score (OHS) and attendance at multi-disciplinary joint school. The pain scores at 0,1,2,3 post-op days, the day of mobilization, inpatient duration, complications, 28 days readmission rates and OHS at 6 and 24 months were compared. Results. Four hundred and fifty two THR (DAA: 219, Posterior: 233) were matched. There was no difference in OHS at 6 months (p=0.07). There was also no difference in pain scores at 0, 1, 2, and 3rd post op days, the day of first mobilization (p=0.32), length of stay (p= 0.3), 28 days readmission (p=0.11) or OHS at 24 months (p=0. 09). 68% of DAA vs 58 % of posterior approach patients achieved planned in-patient duration target of 3 days (p= 0.04). There were six peri-prosthetic femoral fractures in DAA group vs one in posterior approach group (p=0.097). No significant difference was identified for complications, re-operation or 28 days readmission rates between two groups. Discussion. The DAA procedures were performed by two surgeons with extensive prior experience in DAA approach. The potential advantages and complications especially during early learning curve have to be carefully considered by operating surgeon who wishes to start performing DAA approach. The ERAS protocol can potentially reduce the difference in early recovery between two groups. Conclusion. There is no significant difference in clinical outcomes between DAA and posterior approach THR with utilisation of ERAS protocol except potential of discharge from the hospital within three days following the DAA procedure

An audit of a group of dislocations (7 out of 66 hip replacements) revealed a problem with the Charnley Golf Ball cup when used with the posterior approach. Sixty-six consecutive Charnley hip replacements in one institution by one surgeon using the posterior approach over a one year period are presented. The dislocation rate prior to the introduction of the Golf Ball cup was less than 1%. The overall dislocation rate after the introduction of the Golf Ball socket rose to 10.6%. Four patients suffered one dislocation, 2 patients suffered two dislocations and 1 patient suffered a dislocation and spontaneous reduction. Five patients were revisions hip replacements and 61 primary hip replacements. Two of the revisions dislocated. A study of the type of acetabular component type in this series showed there were 17 Wroblewski Angle Bore Sockets (WAB), 11 ogee long posterior wall sockets (OGLPW) and 38 golf ball (GB) sockets making a total of 66 hip replacements. Of the 17 patients with the WAB the dislocation rate was 0 %. Of the 11 OGLPW patients the dislocation rate was 0 %. However in the 38 patients with golf ball sockets the dislocation rate was 18% (7/38). All the dislocations were anterior. The acetabular component position was flexion 15–30 degrees (mode 30 degrees) and anteversion 0–10 degrees (mode 0 degrees). The numbers were not large enough to produce any statistical correlation. All femoral stems were set to 0 degrees anteversion. Following this audit we discontinued the use of the golf ball socket with the posterior approach and have had no further dislocations in primary hip replacement using either the OGLPW or the WAB sockets. Surgeons who use the posterior approach should be warned about the problems of a high anterior dislocation rate when using the Golf Ball cup

Introduction. Traditionally the use of small diameter femoral head (22mm) with the posterior approach has been perceived as an increased risk of dislocation. We present this prospective study of 400 consecutive total hip replacements performed using a 22mm femoral head and the posterior approach. Materials/Methods. Between March 2000 and November 2005 364 patients underwent 400 total hip replacements with a small diameter 22mm head under the care of four different consultants, using a standard posterior approach. All of the femoral implants were cemented using modular C-stems (Depuy Ltd.) and all of the acetabular components were cemented flanged monobloc all-polyethylene components with long posterior wall with a third generation cementing technique. A standard posterior approach was used in all cases, with direct repair of the capsule and short external rotators. Results. There were 252 female and 112 male patients. The average age at the time of surgery was 71.3 years (range 25–92 years) and the average duration of follow-up for surviving patients is 98 months (58–127 months). The average acetabular abduction angle was 43.2 degrees (30–62) and the average femoral offset was 46mm (35–54). Five patients (1.25%) suffered dislocations. Four occurred on a single occasion and were stable on initial reduction and only one required further surgery for recurrent dislocations. Skirted femoral heads had been used in four of these cases, reducing the head/neck ratio (1.76). Conclusion. Total hip replacement using small diameter femoral heads and a posterior approach has provided excellent results and implant longevity, with a low complication rate. Dislocation was the most common complication, occurring in only 1.25% of cases and was associated with the use of a skirted head. This is the largest prospective series coming from single centre, using same approach and same implant design in total hip replacement with 22 mm head

Introduction. Numerous factors have been hypothesized as contributing to mechanically-assisted corrosion at the head-neck junction of total hip prostheses. While variables attributable to the implant and the patient are amenable to investigation, parameters describing assembly of the component parts can be difficult to determine. Nonetheless, increasing evidence suggests that the manner of intraoperative assembly of modular components plays a critical role in the fretting and corrosion of modular implants. This study was undertaken to measure the magnitude and direction of the impaction forces applied by surgeons in assembling modular head-neck junctions under operative conditions where both the access and visibility of the prosthesis may potentially compromise component fixation. Methods. A surrogate consisting of the lower limb with overlying soft tissue was developed to simulate THR performed via a 10cm incision using the posterior approach. The surrogate was modified to match the resistance of the body to retraction of the incision, mobilization of the femur and hammering of the implanted femoral component. An instrumented femoral stem (SL PLUS) was surgically implanted into the bone after attachment of 3 miniature accelerometers (Dytran Inc) in an orthogonal array to the proximal surface of the prosthesis. A 32mm cobalt chrome femoral head was mounted on the trunnion (12/14 taper, machined) of the femoral stem. 15 Board-certified and trainee surgeons replicated their surgical technique in exposing the femur and impacting the modular head on the tapered trunnion. Impaction was performed using an instrumented hammer (5000 Lbf Dytran impact hammer) that provided measurements of the magnitude and temporal variation of the impact force. The components of force acting along the axis aof the neck and in the AP and ML directions were continuously samples using the accelerometers. Results. For all surgeons, the average value of the peak impaction force was 3765±1094N (range: 2358 to 6225N). Head impact was delivered in an average direction of 24.4±7.5 degrees more vertical than the trunnion axis, though this value varies from 14 to 43 degrees between individual surgeons. On average, the off-axis force perpendicular to the trunnion axis was 1586±736N, however, this value ranged from 634 to 2895N with peak loading of both the head and the implant in varus. Almost all of the applied impact was directed within 10 degrees of the mid-plane of the stem (average deviation: 2.5±5.9 degrees of with only a small force directed anteriorly or posteriorly (average force: 140±396N, anterior). The variability in the magnitude and direction of the impaction force was not associated with the level of training or the surgical experience of the participants (p>0.05). Conclusions. This study shows that large off-axis forces are developed during manual impaction of modular heads onto stem trunnions via the posterior approach. The variation in magnitude and direction of these forces varies between individual surgeons and is not systematically related to the training or experience of each surgeon in joint replacement. This variability in intraoperative assembly of head-neck junctions may contribute to the severity and incidence of mechanically assisted corrosion in total hip replacement

Traditional posterior approaches to the neck use a vertical craniocaudal incision which often leaves an unsightly scar. An incision along Langer's transverse lines of tension divides only the cross-fibres of the dermis and we have found the results of this approach encouraging: wound healing was uncomplicated and the cosmetic appearance excellent

We describe a posterior approach to the elbow which combines the advantages of both splitting and reflecting the triceps. It gives protection to the ulnar nerve and its blood supply during the operation while providing excellent exposure of the distal humerus. During closure, the triceps muscle can be tensioned, thereby improving stability of the elbow. This approach has particular relevance to unlinked total elbow arthroplasty allowing early rehabilitation of the joint

1. The indications for ischio-femoral arthrodesis are considered. 2. The technique of operation through an open posterior approach is described. 3. Indications for the modified Trumble operation are given. 4. The results of ischio-femoral arthrodesis in a series of forty-seven patients (mostly suffering from tuberculous hip disease) are presented. 5. The writers consider that ischio-femoral arthrodesis is the operation of choice in tuberculous disease of the hip, especially in children

Introduction:. The direct anterior approach for total hip arthroplasty has shown to improve multiple early outcome measures. However, criticisms suggest improved results may be due to selection bias and protocol changes. This study compares mini-incision posterior approach to direct anterior approach performed by one surgeon, controlling for influences other than the surgical approach itself. Methods:. An IRB approved retrospective review was conducted on 150 consecutive primary total hip arthroplasty patients; the first 50 from mini-incision posterior approach, followed by 50 during the learning curve for direct anterior approach, and 50 subsequent cases when the approach was routine. Peri-operative protocols were alike for all groups. Data collection included patient demographics, anesthesia, operative times, discharge disposition, length of stay, VAS pain scores, progression from assistive devices, and narcotic use at follow-up of two and six weeks. Statistical methods included Wilcoxon rank sum, ANOVA, Kruskal-Wallis, chi-square, fisher exact and t-tests. P-value of <.05 was considered significant. Results:. The groups were well-matched for demographics. The anterior group trended towards higher age, BMI, ASA and pre-op VAS scores. Factors favoring the anterior group reaching statistical significance included: decreased length of stay of 1.02 (learning curve) and 1.26 (routine) days (p < .0001); discharge to home instead of a rehab facility, 80% and 84% anterior versus 56% posterior (p = 0.0028); VAS pain scores at two weeks 2.7 and 2.2 anterior versus 5.2 posterior (p < .0001); less narcotic pain medication use at two weeks, 44% and 30% versus 86% (p < .0001). In the anterior groups, walker use was less at two weeks, 20% and 12% versus 74% (p < .0001) and at six weeks, 4% and 2% versus 20% (p=.0018). Conclusion:. Primary total hip arthroplasty using the anterior approach versus the posterior approach allows for more rapid recovery in patients with no significant selection bias or protocol changes, even during the learning curve period

Introduction. We present our experience of the coned hemi-pelvis (‘ice-cream’ cone) implant, using an extended posterior approach to the hip joint, in the management of pelvic bone loss and pelvic discontinuity. Methods. Retrospective study conducted utilising a prospectively collected database. Patients who underwent an ice-cream cone reconstruction between August 2004 – September 2011 were identified. All had a posterior approach to the hip. Femur prepared in the standard fashion. A variety of femoral components used. Demographic data was recorded along with the indication for surgery and outcomes. Results. 16 patients identified. Mean age was 62.2 years. 5 (31.25%) male. 11 (69.75%) female. Indications included; multiple hip revision surgery 4(25%); post Gridlestones for severe hip dysplasia 1 (6.25%); peri-acetabular metastatic deposits 11 (68.75%) from breast, renal, endometrial, prostatic, myeloma primary malignancies. Mean follow-up was 32.06 months. Complications; 1 intra-operative death from tumour embolus; 1 dislocation; 1 superficial surgical site infection. 3 deaths from their primary malignancy. Mean time from prosthesis implantation to death was 14.5 months. All patients at last follow-up were mobilizing. No implant has needed to be revised. Discussion. Pelvic bone loss provides reconstructive challenges. The coned hemi-pelvis is simple to make, easy and versatile to use even when there is little pelvis remaining. It provides a method of negotiating hip reconstruction in patients with severe pelvic bone loss. Orthopaedic surgeons are familiar with the posterior approach to the hip. The ice-cream cone implant can therefore be placed with ease using this well-known approach to the hip

Surgical exposure of the ankle is usually obtained by an anterior approach, especially for replacement arthroplasty. The transfibular approach has been popular for arthrodesis. We describe a new posterior approach to the ankle and posterior subtalar joint based on an extra-articular vertical calcaneal osteotomy behind the subtalar joint. The posterior flap so formed is hinged medially and offers wide exposure of the back of the ankle and posterior subtalar joint. This hinge allows safe and stable reduction of the osteotomised calcaneum, and the plane of dissection follows an ‘internervous plane’ behind the fibula. We have had good results after using this incision in 12 patients with osteoarthritis or rheumatoid arthritis and there have been no difficulties with wound healing

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. Traditionally hip resurfacing has been performed via a posterior approach though other surgical approaches including the Ganz and the anterolateral approach have been well described. In addition it is known that the blood supply of the femoral neck arises largely from posterior structures and it has been postulated that neck narrowing is a consequence of poor post-operative femoral neck vascularity. Our null hypothesis in this study was that the choice of surgical approach does not influence postoperative femoral neck narrowing. We retrospectively measured the diameter of the femoral neck in a series of 135 consecutive patients who underwent uncemented cormet hip resurfacing, with follow up from one to 3 years. Our sample included 50 females and 85 men with an average age of 56.4 years (standard deviation of 9.47). Seventy six patients had a Ganz approach, 5 had an anterolateral approach and 55 had a posterior approach. There were no failures due to femoral neck fracture and no revisions to total hip arthroplasty. Eleven patients required subsequent surgery all of which were due to complications following trochanteric osteotomy. Seven patients needed removal of metalwork and 4 patients had non-union of their osteotomy requiring revision. At one year the posterior approach group had an average of 5.2% neck narrowing versus 2.7% neck narrowing in the Ganz approach group (p value 0.06). At three years the average neck narrowing amongst all patients was 6.8% (standard deviation 3.1%) but the number of patients who had had a Ganz approach was too small to meaningfully apply inference statistics. Our study shows early results which show a statistically significant reduction in the rate of femoral neck narrowing in patients who have had a Ganz approach as compared to a posterior approach for unce-mented hip resurfacing arthroplasty. It also shows a high rate of complications inherent with the Ganz approach which in our patient group are entirely related to the trochanteric osteotomy

Introduction and purpose: We present the results of our surgical method involving nerve decompression, reduction and circumferential spinal fusion via posterior approach for severe spondylolisthesis. Materials and methods: We studied 14 patients with spondylolisthesis and slippage greater than 50%; mean age 24. Mean slip angle 37° and mean preoperative slip 74%. Procedure: Via a posterior approach we performed neural decompression and placed pedicle screws in L5-S1 (in one case we instrumented L4 for associated L4-L5 spondylolisthesis) and iliac screws (except in three cases). We removed the annulus fibrosus, the L5-S1 disc and the rounded proximal edge of the sacrum. Following distraction of L5-S1 we inserted bone graft cages (from 3 to 5). We adjusted the bars with spanners to reduce slippage and achieve final curvature of the spine. The cases were monitored with evoked potentials and epidural catheter. We studied preoperative, postoperative and final check X-rays. The clinical histories were also reviewed. Results: One rupture of the dura. Two patients with anterior slippage of a cage. One posterior slippage of L5 screws, without revision surgery. One postoperative infection resolved by surgical cleaning and antibiotic therapy. After mean follow-up of 32 months the radiographic study showed no pseudoarthrosis. Final mean slippage was 15% and slip angle 5°. Ten patients had no pain or physical limitations. Two presented mild lumbar discomfort and occasional limitation. Conclusions: The procedure we used was shown to be effective in correcting the deformity with excellent clinical results

Introduction. The debate regarding the importance of preserving the blood supply to the femoral head (FH) and neck during hip resurfacing arthroplasty (HRA) is ongoing. Several surgeons continue to advocate for the preservation of the blood supply to the resurfaced heads for both the current HRA techniques and more biologic approaches for FH resurfacing. Despite alternative blood-preserving approaches for HRA, many surgeons continue to use the posterior approach (PA) due to personal preference and comfort. It is commonly accepted that the PA inevitably damages the deep branch of the medial femoral circumflex artery (MFCA). This study seeks to evaluate and measure the anatomical course of the ascending and deep branch of the MFCA to better describe the area in danger during the posterior approach. Methods. In 20 fresh-frozen cadaveric hips, we cannulated the MFCA and injected a urethane compound. The Kocher-Langenbeck approach was used in all specimens. The deep branch of the MFCA was identified at the proximal border of the QF and measurements were taken. The QF was incised medially and elevated laterally, maintaining the relationship of the ascending branch and QF, and distances from the lesser trochanter were measured. The deep branch was dissected and followed to its capsular insertion to assess the course and relation to the obturatur externus (OE) tendon and the conjoint tendon (CT) of the short external rotators. Results. Gross dissection revealed that the transition point from transverse to ascending branch of the MFCA at the anterior surface of the QF was at an average distance of 2.2 cm (range 2–2.3 cm) proximal and 1.2 cm (range 0.5–1.9 cm) medial to the lesser trochanter. The ascending branch runs caudally within fat tissue that divides the QF and OE at an average distance of 1.5 cm (range 0.7–2.3 cm) from the QF greater trochanter insertion. At the superior border of the QF, the MFCA continues as the deep branch posterior to the OE tendon at an average distance of 1.3 cm (range 0.6–1.9 cm) from the OE femoral insertion. The deep branch was noted to enter the capsule at an average distance of 0.3 cm (range 0–0.5 cm) from the distal border of the CT and 1.2 cm (range 0.6–1.9 cm) from the CT femoral insertion. Discussion and Conclusion. The ascending branch of the MFCA runs in the anterior surface of the QF at a distance of 1.5 cm from the femoral insertion. When the QF myotomy is performed, commonly 0.5–0.8 cm from the insertion to the femur, the vessel get disrupted or stays medial to the myotomy and can stretch/disrupt when the femur is dislocated and translated anteriorly. Tenotomies of the OE and CT should stay at least 1.5 cm from the femoral insertion to preserve the deep branch of the MFCA. This study provides unreported topographic anatomy of the ascending and deep branch of the MFCA, which can help develop an improved blood-preserving posterior approach for HRA

Introduction. Total hip arthroplasty is considered to be one of the most successful orthopaedic interventions. Acetabular component positioning has been shown to affect dislocation rates, component impingement, bearing surface wear rates, and need for revision surgery. The safe zones of acetabular component positioning have previously been described by Lewinnek et al. as 5 to 25 degrees of cup version and 30 to 50 degrees of inclination. Callanan et al. later modified the inclination to 30 to 45 degrees. Our aim was to assess whether THA via robotic assisted posterior approach (PA) improves acetabular component positioning compared to fluoroscopic guided anterior approach THA (AA). Methods. Subjects. This study is a matched-pair case-control study using prospectively collected data from THAs done between January 2012 and December 2013. Patients who underwent primary THA using the PA or AA by the senior surgeons (MH and JAR) were included in the study. Ninety-six patients (of 176; 55%) underwent AA and 80 (of 176; 45%) underwent PA THAs. The matching process was performed by an observer blinded to the radiographic outcomes (EK). Patients were matched for sex and BMI +− 8 units. Seventy-nine patients who had AAs were manually matched to 79 patients who had PAs. Surgical Techniques. For the AA THAs, the patient is supine and the approach is performed through a modified smith Peterson approach. Acetabular cup positioning is assessed intraoperatively with fluoroscopy. For the PA THAs, the patient in the lateral position using the posterior approach. Acetabular cup positioning was guided by the MAKO robotic hip system using preoperative CT scans of the involved hip. Radiographic Measurements. The radiographic measurements were done manually using a standardized technique by two observers blinded to the type of arthroplasty performed. Spearman's rank correlation coefficient was used to test user dependent variability. Means were used for final calculations. Statistical Analysis. The average cup inclination and anteversion angles were calculated. Calculation of the number of hips that were in the safe zones of Lewinnek (inclination, 30°–50°; anteversion, 5°–25°) and Callanan (inclination, 30°–45°; anteversion, 5°–25°) regarding inclination, anteversion, and a combination of both were done for both groups. Independent t-tests were performed to compare both groups for sex, BMI, and inclination and anteversion angles. Fisher's exact test was used to compare both groups regarding the number of hips in the safe zones of Lewinnek and Callanan. Relative risk and absolute risk reduction were calculated. Results. There was no significant difference in BMI between the two groups. Intraobserver agreement was found to be .92 and 0.82 for inclination and anteversion, respectively. Compared to fluoroscopic guided THAs, THAs performed with robot assistance were found to be more often in the safe zone of Lewinnek (90% vs. 75%, p=0.02, RR 0.40 [0.19–0.85] p=0.01). This pattern was observed in the zone of Callanan and approached statistical significance (80% vs. 68%, p=0.11, RR 0.64 [0.37–1.10] p=0.11). Conclusion. Compared to fluoroscopic assisted THA, robot assisted THAs are more likely to be within the safe zone of Callanan and Lewinnek

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

Background: The direct anterior approach (DAA) for total hip arthroplasty (THA) has rapidly become popular, but there is little consensus regarding the risks and benefits of this approach in comparison with a modern posterior approach (PA). Methods: 2,147 patients who underwent DAA THA were propensity score matched with patients undergoing PA THA on the basis of age, gender, body-mass index (BMI) and American Society of Anaesthesia classification using data from a state joint replacement registry. Mean age of the matched cohort was 64.8 years, mean BMI was 29.1 kg/m2 and 53% were female. Multilevel logistic regression models using generalised estimating equations (GEEs) to control for grouping at the hospital level were utilised to identify differences in various outcomes. Results: There was no difference in the dislocation rate between patients undergoing DAA (0.84%) and PA (0.79%) THA. Trends indicating a slightly longer length of stay with the PA and a slightly greater risk of fracture, increased blood loss and hematoma with the DAA are consistent with previous studies. Conclusion: On the basis of short-term outcome and complication data, neither approach has a compelling advantage over each other, including no difference in the dislocation risk

Background: Mini-incision surgery (MIS) for total hip replacement (THR) typically uses incisions of 10cm or less and therefore may offer a better cosmetic appearance. Reported advantages of MIS include decreased blood loss, less tissue trauma and decreased pain, all of which are equivocal by six weeks post-surgery, when compared with standard incisions. The aim of this study was to compare patient scar satisfaction and identify potential long-term benefits of this incision when used in the posterior approach for THR. Methods: Two groups of patients who underwent primary THR were reviewed. Group 1 consisted of 43 patients who underwent THR via a mini-incision, with a mean incision length of 9.44cm. Group 2 consisted of 51 patients who had a posterior standard incision, with a mean length of 15.3cm. The average length of follow-up was 12.8 months (range 2 – 48 months). There were no wound complications in either group. Scars were assessed using the validated Manchester Scar Proforma (MSP) and Visual Analogue Scales (VAS), and patients completed a Patient Scar Assessment Scale. Results: The mean combined MSP and VAS scores for Group 1 and Group 2 were 7.2 and 7.1 respectively. The mean Patient Scar Assessment Scale score was 8.8 in group 1, and 10.4 in Group 2. The single parameter that scored highest in the Patient Scar Assessment Scale was the colour of the scar. This did not vary between the two groups of patients. There was no statistical significance in any of the parameters measured. Conclusion: There does not appear to be any cosmetic benefit from MIS, when performing THR via the posterior approach. The length of wound was of little concern to patients, while the colour of the scar was the highest-scoring factor in the Patient Scar Assessment Scale. We therefore conclude that there is no long-term benefit from mini-incision surgery for THR via the posterior approach

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the anterolateral approach to those resulting from the posterior approach. Methods: In 22 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted supero-laterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the antero-lateral approach. Results: During the operation patterns were similar for both groups, except following joint relocation and soft tissue reconstruction; oxygen concentration recovered significantly in the anterolateral group only. The posterior approach resulted in significantly lower (p< 0.01) oxygen concentration at the end of the procedure (22%, SD 31) than the antero-lateral approach (123%, SD 99). Discussion and Conclusion: The anterolateral approach disrupts the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches

Minimal invasive surgery (MIS) is accepted when the scar is 10 cm or less. The anterior and the antero-lateral approaches had gained recently interest in the total hip arthroplasty because they allow complete muscle sparing. The postero-lateral and lateral approaches were propsed to be less satisfactory from this point of view. The goal of this paper was to report an objective and carfull assessment of the advantages of the minimal invasive posterior approach in short stem (Nanos) total hip arthroplasty. Material and methods. From juli 2005 to march 2009 a total of 113 (70 males,53 female) uncemented Nanos-short-stem prothesis were implanted in 111 patients. The patiens average age was 53 years (33-73). The indication for this procedure was predominantly coxarthrosis. In all cases a minimal invasive posterior approach was used. The mean follow up period was 2,5 years (range 6 months- 4,5 years). The patients were assessed using Harris Hip Score and radiologically to detect any bone changes, the stand of the prothesis and peri-articular ossifications. Results. The perioperative Harris Hip Score was 53 (28-77), postoperative was 94 (86-100). Untill now we have not discovered any prothesis specific complications. Radiological follow up examinations showed the development of increasing trabecular reinforciment of the femoral neck and pertrachanteric regions. There is no evidence of any loosing or migration of the prothesis. No luxation. Calcification was noted in 8 cases (Grad 1), 4 cases(Grad 2), 1 case (Grad 3). In 3 cases we have to change the cup because of malposition. Conclusion. the stem design of Nanos-short-stem prothesis allowed a metaphyseal intertrochanteric multipoint primary fixation. The surgical technique using posterior approach give a good access to the femur and acetabulum. It allows intraoperative ROM as well as extention in the event of intraopertive complications. Long term studies still be needed

We report eight cases of sacrococcygeal chordoma treated by high sacral resection through S2 by a posterior approach, with the intention of achieving radical removal. The technique we describe is easier than the combined abdominosacral approach, and there have been no serious intra-operative or postoperative complications. The major technical problems were the margins of excision in the sacrum itself (one recurred) and in the perirectal soft tissues (four recurred), and the preservation of sacral nerve roots. When both S2 roots were preserved, sphincter problems were mild and reversible. One patient died from recurrence 32 months after operation and one was lost to follow-up at eight months. Six patients are alive with a median survival of three years; three of them are free of disease after 22, 36 and 80 months respectively. These results indicate the possibility of surgical cure of this malignant tumour

Recent National Institute for Health and Care Excellence (NICE) guidance has advised against the continued use of the Thompson implant when performing hip hemiarthroplasty and recommended surgeons consider using the anterolateral surgical approach over a posterior approach. Our objective was to review outcomes from a consecutive series of Thompson hip hemiarthroplasty procedures performed in our unit and to identify any factors predicting the risk of complications. 807 Thompson hip hemiarthroplasty cases performed between April 2008 and November 2013 were reviewed. 721 (89.3%) were cemented and 86 (10.7%) uncemented. 575 (71.3%) were performed in female patients. The anterolateral approach was performed in 753 (93.3%) and the posterior approach with enhanced soft tissue repair in 54 (6.7%). Overall, there were 23 dislocations (2.9%). Dislocation following the posterior approach occurred in 13.0% (7 of 54) in comparison to 2.1% (16 of 753) with the anterolateral approach (odds ratio (OR) 8.5 (95% CI 2.8 to 26.3) p < 0.001). Surgeon grade and patient history of cognitive impairment did not have a significant impact on dislocation rate. Patients were discharged home in 459 cases (56.9%), to a care home or other hospital in 273 cases (33.8%). 51.8% (338 of 653) returned home within 30 days. 75 died during their admission (9.3%). 30-day mortality was 7.1% and 1-year mortality was 16.6%. Intraoperative fracture occurred in 15 cases (1.9%) of which 14 were cemented. Superficial or deep infection occurred in 33 cases (4.1%). We recommend against the continued use of the posterior approach in hip hemiarthroplasty, as enhanced soft tissue repair did not reduce dislocation rates to an acceptable level. Our findings, however, demonstrate satisfactory results for patients treated with the Thompson hip hemiarthroplasty performed through an anterolateral approach. We suggest that the continued use of the Thompson implant in a carefully selected patient cohort is justifiable

In 12 patients, we measured the oxygen concentration in the femoral head-neck junction during hip resurfacing through the anterolateral approach. This was compared with previous measurements made for the posterior approach. For the anterolateral approach, the oxygen concentration was found to be highly dependent upon the position of the leg, which was adjusted during surgery to provide exposure to the acetabulum and femoral head. Gross external rotation of the hip gave a significant decrease in oxygenation of the femoral head. Straightening the limb led to recovery in oxygen concentration, indicating that the blood supply was maintained. The oxygen concentration at the end of the procedure was not significantly different from that at the start. The anterolateral approach appears to produce less disruption to the blood flow in the femoral head-neck junction than the posterior approach for patients undergoing hip resurfacing. This may be reflected subsequently in a lower incidence of fracture of the femoral neck and avascular necrosis

Aims: To compare the efþcacy and possible complications of two approaches in the management of unstable burst fractures of the thoracolumbar spine. Methods: retrospective review of two consecutive series of patients with a minimum 2Y follow-up. Group 1, 22 patients operated up to 1998: isolated posterior approach using a rod-screw instrumentation, posterior grafting and correction of the kyphosis by in situ contouring of the rods. Group 2, 15 patients operated from 1998: isolated approach for strut grafting with rib, iliac crest or þbular fragments and a Z-Plate instrumentation. Results: preop, postop and 2Y FU kyphosis averaged respectively 11û/11.6û, 2.4û/-2û, 6.5û/5û in group 1 and 2. Initial correction was better with the posterior in-situ contouring of the rods but there was more loss of correction at þnal follow-up (7û). With the anterior approach, initial correction was more difþcult to obtain but loss of correction was less (4.1û). Though more invasive, the thoracic, thoracolumbar or lumbar anterior approaches did not lead to complications in our series. In 1/3 of the patients operated by anterior approach, a two level fusion could be performed instead of a three level fusion. Conclusions: the two procedures gave similar þnal results but an early surgery was necessary in the case of a posterior approach whereas correction remained possible after a greater delay with the anterior procedure. The anterior approach allowed a shorter fusion in cases where the inferior part of the vertebral body was not severely damaged